Do Drinking and Smoking Go Together?

Heavy drinkers tend to be heavy smokers. Drinking appears to prompt smoking in real-life situations; whether smoking prompts drinking is uncertain. Alcohol-tobacco interactions are particularly important during attempts to achieve or maintain abstinence from either drug. Studies suggest that alcoholics who quit smoking are more likely to succeed in alcoholism treatment. However, data consistently demonstrate that alcohol consumption may precipitate smoking relapse.

A lcohol and tobacco seem to go to nance and cessation stages. Further Existing evidence does not rule out gether: Drinkers smoke and more, it is not an exhaustive review of the possibility that the overall correla smokers drink. In addition, the literature but rather an illustration tion between drinking and smoking heavier drinkers tend to be heavier of some key issues. may reflect primarily the heavy end smokers. Use of alcohol and tobacco of the drinkingsmoking continuum. may be related in two ways. First, For example, researchers have found people who drink may also smoke

BETWEENPERSON INTERACTION
smoking prevalence rates to be much (and vice versa); this is referred to as higher among alcoholics than among the betweenperson interaction. Sec

The Maintenance Stage
nonalcoholics (Cyr and Wartmen 1988; ond, people who use both drugs may Alcoholtobacco interactions are promi DiFranza and Guerrera 1990) and even use them together in the same situa nent in the maintenance phase of ad tions. This is referred to as the situa greater than 90 percent in some stud tional interaction. Betweenperson diction. Most smokers (i.e., 86 percent) ies (Maletzky and Klotter 1974; Bobo and situational relationships are inde drink alcohol, and smokers are 1.32 pendent of each other: Each can theo times more likely to drink than are non SAUL SHIFFMAN, PH.D., is a professor of retically occur without the other, and smokers (Friedman et al. 1974). This psychology and MARK BALABANIS is a each can be explained by different relationship holds for both men and graduate student in clinical psychology women but is slightly stronger among potential mechanisms.
at the Department of Psychology, women. Conversely, smoking preva This article briefly reviews the University of Pittsburgh, Pittsburgh, nature of the relationships between lence is 75 percent higher among Pennsylvania. drinking and smoking and examines drinkers than among nondrinkers their effect on alcoholism treatment and (Abelson et al. 1973).
This article summarizes material pre smoking cessation. Studies on smoking The link between drinking and viously published in Shiffman, S., and and drinking have been conducted with smoking shows a doseresponse rela Balabanis, M. Associations between reference to three stages of drug use: tionship. That is, heavier drinkers tend alcohol and tobacco. In: Fertig, J.B., (1) initiation (i.e., initial exposure to and to be heavier smokers (Friedman et al. and Allen, J.P., eds. Alcohol and To use of a drug), (2) maintenance (i.e., 1991; Abrams et al. 1992 MD, 1995MD, . 1992. Alcoholics may also smoke more heavily than nonalcoholic smok ers. In one study, for example, the average smoking rate for alcoholics was 48.7 cigarettes per day (Maletzky and Klotter 1974), more than double the national average for smokers (U.S. Department of Health and Human Services 1988). Also, drinking and smoking rates correlated very highly among alcoholics but not among non alcoholic control subjects (Maletzky and Klotter 1974). Conversely, alco holism is much more prevalent among smokers than nonsmokers, particularly among women (DiFranza and Guerrera 1990;Covey et al. 1994).
Thus, prevalence as well as rates for drinking and smoking are linked in the general population, but the rela tionship appears particularly strong at higher levels of use: Heavy drinkers are likely to be heavy smokers and vice versa.

CESSATION AND RELAPSE
The effect of heavy drinking on smok ing cessation is uncertain. According to Carmelli and colleagues (1993), smokers who were lighter drinkers were more likely to report quitting smoking over a 16year followup peri od. In addition, DiFranza and Guerrera (1990) reported that although alco holics were as likely as nonalcoholic subjects to try to quit smoking, they were less likely to succeed. Similarly, smokers with past alcohol problems were less likely to quit smoking suc cessfully (Hughes 1993). In a sample of alcoholics, Bobo and colleagues (1987) reported that severity of alco holism was associated with failure to quit smoking. However, Hughes and Oliveto (1993) found that drinking rate had no influence on smoking relapse rates. Covey and colleagues (1993,1994) similarly concluded that a his tory of alcoholism had no effect on smoking cessation; however, a sub group of alcoholic men with histories of depression had significantly lower success rates. Thus, current or past alcoholism may impede smoking cessation efforts only in a subgroup of smokers.
Some addiction specialists have speculated that attempting or achiev ing smoking cessation might increase the risk of alcoholism treatment fail ure. Studies to date, conducted largely in reallife settings, suggest that alco holics who quit smoking are more likely to succeed in alcoholism treatment (Shiffman and Balabanis 1995).

The Maintenance Stage
In laboratory studies, smokers increase smoking in response to alcohol con sumption. In most early studies of this type, subjects consumed repeated doses of alcohol over 1 or more days.
Smoking rate and amount of alcohol was assessed over whole days. This approach did not evaluate the effect of drinking on smoking at the moment of alcohol ingestion. However, subsequent studies demonstrated that single doses of alcohol increase smoking, either increasing the number of cigarettes smoked or by resulting in larger puffs when the number of cigarettes was held constant (Nil et al. 1984;Mintz et al. 1985).
Results of laboratory studies are supported by smokers' selfreports that drinking prompts them to smoke in reallife situations. In one study, for example, 67 percent of smokers sur veyed stated that they smoked when they drank (McKennell and Thomas 1967). However, studies have ques tioned the validity of selfreports as measures of smoking patterns (Shiff man 1993; Shiffman et al. 1994).
Shiffman and colleagues (1994) monitored the association between drinking and smoking using small palm top computers with which subjects recorded the circumstances surrounding each smoking event and their mood at that time. The computers also "beeped" subjects at random to assess nonsmok ing moments in similar fashion. Sub jects were almost twice as likely to report recent drinking when they had been smoking. Moreover, alcohol con sumption was the single strongest factor associated with smoking. Statis tical analysis showed that the associa tion between drinking and smoking could not be attributed to the effects of some third variable, such as mood.

Does Smoking Prime Drinking?
No human studies have been conducted to assess whether smoking primes drinking (i.e., increases the probability of subsequent drinking). Only one ani mal study on this topic appears to exist. Potthoff and colleagues (1983) showed that rats implanted with continuous slowrelease nicotine pellets doubled their daily alcohol intake. This result emphasizes the need for further re search on this direction of influence.

Cessation and Relapse
Data consistently demonstrate that alcohol consumption may precipitate smoking relapse. This has been dem onstrated in several studies in which al cohol consumption increased the risk of smoking relapse, compared with situations in which the smoker was tempted but did not relapse (Shiffman 1982;Colletti et al. 1981;Cummings et al. 1985;Baer and Lichtenstein 1988). These results were confirmed in a re cent study in which subjects' relapse experiences were monitored using palmtop computers (Shiffman et al. in press). Drinking also was more common in situations in which people smoked their first cigarette after having temporarily abstained than at randomly sampled times. Some evidence indicates that the role of alcohol in promoting relapse increases later in abstinence (Cummings et al. 1985). No studies have addressed whether smoking acutely triggers alcohol relapse.
Researchers have speculated that alcohol may enhance relapse risk by releasing inhibitions that restrain smok ing, thereby undermining coping (Shiffman 1982). However, the evi dence for this is inconsistent (Curry and Marlatt 1985;Shiffman et al. in press), and other mechanisms also are plausible. For example, priming with one drug may reinstate the use of other drugs (de Wit and Stewart 1983;Stewart and Wise 1992). Conditioned associa tions between drinking and smoking also may underlie the association of drinking with smoking relapse (Abrams et al. 1992;Niaura et al. 1988).

MECHANISMS
Various explanations have been pro posed to account for smokingdrinking associations. For example, use of alco hol and tobacco may reflect a common genetic propensity (Swan et al. 1994). Alcohol and tobacco also may induce crosstolerance for each other (Burch et al. 1988). Tolerance is an aspect of addiction in which increasingly stronger doses of a drug are required to produce a given effect. Crosstolerance is a phenomenon whereby tolerance to one drug induces tolerance to a different drug. Although these explanations may account for betweenperson differences, they do not account for situational ef fects (Swan et al. 1994).
Some researchers have proposed that people use tobacco when they drink to counteract alcohol's depressant effects with nicotine's stimulant effects (Lyon et al. 1975). In addition, alcohol may release inhibitions that restrain smoking (Shiffman 1982;Shiffman et al. 1994). 1 These suggested mechanisms might explain situational aspects of the alcoholtobacco association.
Finally, a stresscoping theory proposes that people resort to drug use-especially multiple drug usewhen stressed beyond their capacity to cope (Wills and Shiffman 1985). High stress (a situational factor) or poor coping skills (a personal factor) may prompt a person to use alcohol and tobacco together to cope.
Differing theories of the alcohol tobacco link need not be mutually ex clusive. First, different theories may relate to different aspects of the same basic mechanism. For example, some of the association between drinking 1 In this context, the term "inhibitions" refers to the general concept of motivational and cogni tive resolve that smokers use in order to refrain from smoking. and smoking may result from common genetic factors in alcohol and tobacco use. However, these genetic contribu tions may be expressed as different aspects of personality that may them selves be heritable (Plomin 1990). Thus, genetic and personality explanations of the alcoholtobacco link may not only be compatible-they may be two versions of the same theory. Second, different mechanisms may work simul taneously or even synergistically. For example, nicotine may exhibit both antianxiety and stimulant properties. Thus, people may smoke while drink ing in an attempt to overcome stress more effectively while maintaining alertness and coordination (Lyon et al. 1975).

RESEARCH RECOMMENDATIONS
Although much is known about the alcoholtobacco link, much remains to be discovered. Future research should attempt to establish whether the ob served relationship between alcohol and tobacco use holds only for heavy users or is truly dosedependent throughout the range of use. In addition, research should determine the situational, as well as the individual, interactions of al cohol and tobacco. This approach re quires studies in reallife environments as well as in the laboratory to ensure ecological credibility.
Research should focus on develop ing and testing theoretical models of the alcoholtobacco link. Although re searchers have speculated about mech anisms linking drinking and smoking, almost no studies have actually tested any theory.
Finally, the influence of tobacco on alcohol should be assessed, with particular attention given to the effect of smoking cessation on alcoholism treatment. Such research should clarify how smoking urges, feelings of depri vation relating to cigarettes, and symp toms of nicotine withdrawal may affect alcohol abstinence. ■